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Rheumatoid Arthritis Role of Primary Care

Rheumatoid Arthritis Role of Primary Care. Professor Paul Emery ARC Professor of Rheumatology Head of Academic Unit of Musculoskeletal Disease University of Leeds Institute of Molecular Medicine Clinical Director Rheumatology LTHT Leeds, UK. What is Arthritis?. Joint failure

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Rheumatoid Arthritis Role of Primary Care

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  1. Rheumatoid ArthritisRole of Primary Care Professor Paul Emery ARC Professor of RheumatologyHead of Academic Unit of Musculoskeletal Disease University of Leeds Institute of Molecular Medicine Clinical Director Rheumatology LTHT Leeds, UK

  2. What is Arthritis? • Joint failure • Two major types (causes) Inflammatory: rheumatoid arthritis (RA) and Degenerative: osteoarthritis (OA)

  3. Problems in Arthritis • Perception: Nothing can be done • Priority: Arthritis is non life-threatening cf Cancer/Heart disease Not part of NSF

  4. Problems in Arthritis Presents late, but irrelevant As even if could see early • No accurate diagnosis • No effective therapy • All have changed

  5. Arthritis: extent of the problem • Arthritis and bone diseases are increasing in incidence, prevalence and importance • Ageing population age wave • Arthritis alone most common symptom over 55 • Predicted no.1 problem in future • Largest cause of medical sickness Many patients referred inefficiently/inappropriately

  6. Arthritis – extent of the problem • Arthritis Care Report [February, 2002] • 1 in 5 of population has some form of arthritis • 72% of people with arthritis meet legal definition of disability • 20% of GP consultations are arthritis related (25% are dissatisfied with treatment)

  7. Impact on quality of life Sprangers, 2000

  8. New Approaches • Complete rethink required for diseases previously regarded as untreatable • Successful therapies for many conditions • Assessment should be evidence-based and rapid • Rapid because either painful (delay leads to chronicity) or serious (delay leads to fatality) missed “window of opportunity” • Cost enormous - £billions, research money restricted

  9. Strange Truths • RA is curable • It can only be done with primary care • Leeds can be first to achieve it

  10. RA Current Concepts

  11. RHEUMATOID ARTHRITISOverview • Chronic inflammatory disease of unknown etiology: multi-hit hypothesis • Complex development: persistent inflammation in predisposed individual leads to chronicity • Fluctuating clinical course characterized by -Progressive destruction of synovial joints with loss of cartilage and bone -Damaged ligaments and tendons -Loss of physical function and quality of life -Premature death

  12. RHEUMATOID ARTHRITISEconomic Burden • Estimated direct costs of RA were US $8.74 billion in 1994, 0.3% of the gross domestic product (GDP) • In the UK, average RA outpatient cost/case/year was £798 (US $1,126) and £1,253 (US $1,769) per inpatient in 1997 • RA costs average: • 49% of cost of cancer • 68% of cost of stroke • 82% of cost of coronary heart disease • 5 times cost of motor vehicle accidents • Indirect costs • 3 to 4 times higher than direct costs • Lifetime costs £500,000

  13. RHEUMATOID ARTHRITISSocial and Psychological Burden • Impact on Patient: • Moderate disability within 2 years of diagnosis, severe by 10 years (relentless spread; analogous to malignancy) • Inability to work within 10 years of onset • approximately 50% of RA patients • Feelings of helplessness and other psychological distress • Potential inability to carry out social role

  14. RHEUMATOID ARTHRITISDisease Progression Normal Knee Joint Early Rheumatoid Arthritis Established Rheumatoid Arthritis Adapted with permission from:Choy EHS, Panayi GS. N Engl J Med. 2001;344:907–916.

  15. RHEUMATOID ARTHRITISPresenting Signs and Symptoms • Symmetric joint pain • Swelling of small peripheral joints • Morning joint stiffness of variable duration • Fatigue, malaise/depressionmay precede other symptoms • Insidious onset • Life-long disease

  16. TREATMENT OF RHEUMATOID ARTHRITISConventionalGeneral Approach • Start treatment early to prevent joint damage • Institute general therapeutic measures: education, exercise, rest, joint protection, physical therapy • Prescribe medications for symptom relief • Prescribe DMARDs (Disease Modifying anti-Rheumatic Drugs) to prevent joint damage and induce remission

  17. TREATMENT OF RHEUMATOID ARTHRITISGoals of Therapy • Relieve symptoms, including fatigue, pain, swelling, and stiffness • Prevent joint destruction, loss of joint function, deformity, disability, and early death • Preserve quality of life • Achieve clinical remission

  18. Nodular, erosive rheumatoid arthritis

  19. Early Arthritis Clinics (EAC) WHY? - Damage occurs early - Results of failure to treat. - Model system of care. HOW? - Education, finance, enthusiasm. WHAT IF? - Reduced wait - Better outcome - Innovative approaches to therapy.

  20. Inflammation Function Early Treatment of RA and the Goal of Preventing Long-Term Disability Severity Time Interventions Ahmed K, Emery P.. Challenges in Rheumatoid Arthritis. Oxford, England: Blackwell Science; 1999:106-115.

  21. Paradigm • Inflammation is bad • Inflammation is treatable Inflammation x Time =Damage

  22. What is needed? • Good contacts with primary care • Education re importance of early phase

  23. Inception cohorts (EAC) allow: • Differentiating the effects of Drugs/Disability/Disease • Prediction • Better outcome for both good and poor outcome patients

  24. Yorkshire Early Arthritis Register (YEAR): Background • Leeds Early Arthritis Project (LEAP) • Region wide (15 centres) register of all new RA patients • Co-ordinated programme to standardise management and improve outcome of early RA on a regional basis

  25. YEAR: Participating Centres

  26. Delay in presentation of inflammatory arthritis Mean time from first symptom to specialist appointment for patients with RA(Birmingham EAC) • 1988 14.2 months • 1993 3.4 months • Note: hard to see RA patients quicker

  27. Which symptoms? Target Population? • Early RA • Inflammatory arthritis • Potential inflammatory arthritis • All new onset non-traumatic arthritis Target population depends on purpose of clinic and resources • Logic for all inflammatory arthritis • Entry into secondary care

  28. Seeing potential RA or all new arthritis? Practical Approach Refer all patients with: • New onset arthritis (non-traumatic) and/or • Symptoms of inflammation • EM Stiffness • Swelling • Response to NSAIDs • Are symptoms/signs accurate?

  29. Which Tests Before Referral? • Acute phase response • X ray • RF/anti-CCP/ autoAb • Or None

  30. Reasons that Tests are Unhelpful • Waiting for results delays referral • A large proportion of appropriate patients will be negative • X ray 80% • CRP 50% • RF/CCP 40% • Negative tests deter referral • Do anti-CCP if NOT referring

  31. MRI at Presentation • Presence of erosions diagnostic prognostic -level of synovitis -level of bony oedema

  32. Size of US lesions seen by radiology (resolution) Wakefield et al A&R1999 • Xray sees 9% of small US lesions • Xray sees 57% of moderate/large US lesions i.e. Radiology insensitive for small lesions Note • In early RA 90% of all HRUS lesions are small • In late RA 63% of all HRUS lesions are small i.e. majority of erosions small (esp. early) Radiology will miss most cortical breaks especially in early disease

  33. Outcome of Early Assessment • Over half of ACR (RA)patients seen and treated within 12 weeks went into remission • After 12 weeks less than 10% • Early treatment effective ?essential

  34. Early IA algorithm Inflammatory Arthritis No Yes Imaging SymptomaticTreatment Duration > 12 weeks No Yes Yes Recurrence after single CS dose ACR +ve No Yes No SelfLimiting Confirmed RA Undifferentiated arthritis

  35. Sonography of Subclinical Synovitis 26 patients with clinical monoarthritis • 35% sonographic oligoarthritis (> 1 joint) • 25% sonographic polyarthritis Total number of joints US synovitis 800 Number of joints 700 600 500 400 300 200 100 0 Asymptomatic Painful but not Clinical synovitis swollen Clinical findings Prevalence of US detected synovitis in joints which were asymptomatic, clinically painful but not swollen, and clinically synovitis joints. Wakefield et al. Ann Rheum Dis 2004; 63:382-388

  36. Anti-TNFs: A major therapy Key therapeutics representing a dramatic improvement in treating RA patients 1930-40 1950 1960 1988 1995 1999+ Combo MTX Steroid NSAID Gold Penicillamine Sulfasalazine Hydroxychloroquine Anti-TNF

  37. PREMIER Study Clinical Remission by DAS28<2.6 *p<0.001 for adalimumab + MTX vs MTX alone and adalimumab alone

  38. PREMIER Study Adalimumab + MTX 12 Adalimumab 10.4 10 MTX 8 6 Change from Baseline ** 5.5 5.7 4 3.5 ** 3 ** 2 * 1.9 2.1 * * 1.3 0.8 0 0 0 0 0 26 52 78 104 Change in Total Sharp Score * p<0.001 for adalimumab + MTX vs MTX alone and adalimumab alone **p<0.001 for adalimumab vs MTX alone

  39. Very Early use of Anti-TNF • Early RA • Poor prognosis • Previously untreated • Double-blind, placebo-controlled/ Independent assessors • All patients MTX +/- anti-TNF

  40. TNF 20 Key study features • Early RA • Poor prognosis (PISA>3) • Previously untreated • Frequent MRI assessments • Double-blind, placebo-controlled • Independent assessors • Benefits of anti-TNF/MTX over MTX alone Quinn et al A&R 2005

  41. MRI synovial volumes pre- & post- infliximab

  42. anti-TNF at presentation produces long-lasting benefit (one year after stopping therapy) Quinn et al A&R 2005 0 0 14 30 46 54 78 104 -20 -40 -60 -80 -100 MTX Treatment HAQ MTX + placebo HAQ MTX + Infliximab % change RAQoL MTX + placebo RAQoL MTX + Infliximab Anti-TNF treatment 1 2 years

  43. TNF Results at 2yrs • Follow up 1 year after last infusion • NO FLARES in responder patients • New approach to therapy? • Guide response/therapy especially in early disease

  44. Coordinated Programme To Prevent Arthritis Dr Jackie Nam Rheumatology Fellow Professor Paul Emery Arc Professor of Rheumatology Academic Unit of Musculoskeletal Disease Chapel Allerton Hospital

  45. Hypotheses • In the pre-clinical phase of RA, patients present with non-specific musculoskeletal complaints • These patients can be identified by performing an anti-CCP antibody test • Doing a blood test in those patients who would not be otherwise referred, will enable us to see pre-RA patients earlier

  46. Aims • To determine whether we can identify an enriched population of anti-CCP Ab (+) patients by screening those patients with new-onset, non-traumatic musculoskeletal complaints • To document the initial presenting complaint of these patients • To determine the initial cost of this community screening process • To develop a model for early diagnosis of RA • Prevent progression to RA

  47. Endpoints • Proportion of community patients with new-onset, non-traumatic musculoskeletal complaints who are anti-CCP Ab (+) • Proportion of patients who develop an inflammatory arthritis (IA) by 12 months • Proportion of patients who develop RA by 12 months

  48. How can you help in Primary Care? Patients for referral: • Any new musculoskeletal complaint • ≥ 18 years

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